OBJECTIVE: To examine the association between surgical volume and survival of women with early-stage cervical cancer who underwent radical hysterectomy. METHODS: This is a nationwide multicenter retrospective study examining consecutive women with clinical stage IB1-IIB cervical cancer who underwent radical hysterectomy and pelvic lymphadenectomy from 2004 to 2008 (N=5,964). The surgical volume per site over the 5-year period was defined as low-volume (fewer than 32 surgeries, 46 [39.7%] institutions, n=649 [10.9%]), mid-volume (32–104 surgeries, 60 [51.7%] institutions, n=3,662 [61.4%]), and high-volume (105 surgeries or more, 10 [8.6%] institutions, n=1,653 [27.7%]). Surgical volume-specific survival was examined with multivariable analysis and propensity score matching. RESULTS: The median number of surgeries per site was 44 (interquartile range, 17–65). The 5-year disease-free survival rates among stage IB1-IIB disease were 77.2%, 79.9%, and 84.5% for low-, mid-, and high-volume groups, respectively. On multivariable analysis, women in high-volume centers had a decreased risk of recurrence (adjusted hazard ratio [HR] 0.69, 95% CI 0.58–0.82, P<.001) and all-cause mortality (adjusted HR 0.73, 95% CI 0.59–0.90, P=.003) compared with those in mid-volume centers. Specifically, women in high-volume centers had a decreased risk of local recurrence (adjusted HR 0.62, 95% CI 0.49–0.78, P<.001) but not distant recurrence (adjusted HR 0.85, 95% CI 0.67–1.06, P=.142) compared with those in mid-volume centers. Among 1,700 women with clinical stage IB1 disease treated with surgery alone, surgery at high-volume centers was associated with a decreased risk of recurrence (adjusted HR 0.45, 95% CI 0.25–0.79, P=.006) and all-cause mortality (adjusted HR 0.29, 95% CI 0.11–0.76, P=.013) compared with surgery at mid-volume centers on multivariable analysis. After propensity score matching, surgery at high-volume centers remained an independent prognostic factor for decreased recurrence (adjusted HR 0.69, 95% CI 0.57–0.84, P<.001) and all-cause mortality (adjusted HR 0.75, 95% CI 0.59–0.95, P=.016) compared with surgery at mid- and low-volume centers on multivariable analysis. CONCLUSION: Hospital volume for radical hysterectomy may be a prognostic factor for early-stage cervical cancer. Surgery at high-volume centers is associated with decreased local recurrence risk and improved survival.

This was a nation‐wide retrospective study in Japan examining women who underwent radical hysterectomy for clinical stage IB–IIB cervical cancer with pelvic and/or para‐aortic lymph node metastasis between 2004 and 2008. Time to recurrence or death and patterns of disease recurrence were compared based upon the adjuvant treatment pattern: whole pelvic radiotherapy alone (n = 253), concurrent chemoradiotherapy (CCRT, n = 502) and chemotherapy alone (n = 319). Women who received chemotherapy alone had similar recurrence (5‐year rates, 36.6% vs. 34.1%, adjusted‐hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.70–1.28, P = 0.72) and cervical cancer mortality (24.7% vs. 21.8%, adjusted‐HR 0.96, 95% CI 0.67–1.38, P = 0.83) rates compared to those who received CCRT on multivariate analysis. However, when recurrence patterns were stratified, chemotherapy treatment was independently associated with decreased risk of distant recurrence (5‐year cumulative rates, 19.2% vs. 24.6%, adjusted‐HR 0.47, 95% CI 0.31–0.71, P < 0.001) but increased risk of local recurrence (23.9% vs. 14.3%, adjusted‐HR 2.03, 95% CI 1.34–3.08, P = 0.001) compared to CCRT. Non‐squamous histology, parametrial involvement and high lymph node ratio were independent predictors for local recurrence, and presence of multiple risk factors was associated with high 5‐year cumulative local recurrence rate in the chemotherapy group: no risk factor 3.9%, single factor 14.2–22.1%, and multiple risk factors 27.8–71.9% (P < 0.001). In conclusion, while exhibiting different recurrence patterns, systemic chemotherapy may be as effective a postoperative treatment as radiation‐based therapy in node‐positive high‐risk stage IB–IIB cervical cancer. When tumor exhibits certain risk factors, chemotherapy alone is likely insufficient for local control and adding pelvic irradiation to systemic chemotherapy is recommended in this subgroup.

Matsuo K, et al. J Gynecol Oncol. 2017 Sep;29(1):e11. https://doi.org/10.3802/jgo.2018.29.e11

This study seeks to identify risk factors associated with ovarian metastasis and to characterize a population with minimum risk of ovarian metastasis in young women with stage IB–IIB cervical cancer. This was a nation‐wide multicenter retrospective study in Japan examining consecutive cases of surgically‐treated women with clinical stage IB–IIB cervical cancer who had oophorectomy at radical hysterectomy (n = 5,697). Multivariable analysis was performed to identify independent risk factors for ovarian metastasis. Ovarian metastasis was seen in 70 (1.2%, 95% confidence interval 0.9–1.5) cases. In the entire cohort, adenocarcinoma, lympho‐vascular space invasion, uterine corpus tumor invasion, and pelvic/para‐aortic nodal metastases remained independent risk factors for ovarian metastasis (all, adjusted‐p < 0.05). In a sensitivity analysis of 3,165 women aged <50 years (ovarian metastasis, 1.0%), adenocarcinoma, parametrial tumor involvement, uterine corpus tumor involvement, and pelvic/para‐aortic nodal metastases remained independent risk factors for ovarian metastasis (all, adjusted‐P < 0.05). In the absence of these five risk factors (representing 46.1% of women aged <50 years), the incidence of ovarian metastasis was 0.14%. With the presence of adenocarcinoma alone (representing 18.9% of women aged <50 years), the incidence of ovarian metastasis was 0.17% and was not associated with increased risk of ovarian metastasis compared to the subgroup without any risk factors (p = 0.87). In conclusion, nearly two thirds of women aged <50 years with clinical stage IB–IIB cervical cancer had no risk factor for ovarian metastasis or had adenocarcinoma alone: these subgroups had ovarian metastasis rates of around 0.1% and may be a candidate population for ovarian conservation at surgical treatment.

Effectiveness of adjuvant systemic chemotherapy for intermediate-risk stage IB cervical cancer Effectiveness of adjuvant systemic chemotherapy for intermediate-risk stage IB cervical cancer

National health insurance coverage for the laparoscopic staging surgery for patients with stage IA endometrial cancer started from April 2014 in Japan. We conducted this retrospective study to evaluate the surgical outcomes of the laparoscopic surgery for patients with low-risk endometrial cancer compared with those of the laparotomy. A total of 120 patients with presumed low-risk endometrial cancer, who were treated at Tottori University Hospital between 2005 and 2016, were eligible for this study. The laparoscopic staging surgery included only the pelvic lymphadenectomy and not the para-aortic lymphadenectomy. We evaluated the discrepancy between preoperative presumption and postoperative diagnosis of recurrent risk factors. Forty patients underwent the laparoscopic surgery and 80 patients received the laparotomy. The laparoscopic surgery resulted in less intraoperative blood loss and shorter hospital stay. The operative time was significantly longer for the laparoscopic surgery compared with the laparotomy, but this difference was not seen in obese patients with a body mass index ≥30 kg/m2. The type of the surgical procedure did not affect the incidence of perioperative complications. Among 120 patients, 104 (86.6%) were diagnosed as FIGO stage IA, 118 (98.3%) with endometrioid adenocarcinoma grade 1 or 2, and 107 (89.1%) with myometrial invasion depth <50%. The laparoscopic staging surgery is a feasible and safe alternative to the laparotomy for patients with presumed low-risk endometrial cancer, especially for obese patients. To perform the laparoscopic surgery for patients with stage IA endometrial cancer under the current national health insurance system, it is important to limit the candidates to low-risk disease based on a precise diagnosis before the surgery.